Tobacco 21 Violation

Please complete this form if you believe that a tobacco retailer in Howard County has violated the Tobacco 21 law by:

Selling tobacco products to anyone under the age of 21 and/or

Failing to keep tobacco products secured behind the counter in an area accessible only to the licensed retailer and employees

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1. Today’s Date (Required.)

Date

Date

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2. Describe the violation (Required.)

Retailers Information

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3. Retailer’s Information (Required.)

Name of Business

Street Address

City

Zip Code

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4. Provide your name and contact information if you would like to be contacted by a Howard County Health Department representative.

First Name

Last Name

Phone Number

Email